Big Black Brain Phenomenon: Understanding Clinicoradiological Dissociation in Non-Accidental Traumatic Brain Injury in Children

Pediatric traumatic brain injury (TBI) is a major cause of concern worldwide. Non-accidental traumatic (NAT) brain injury is common in infants. Since infants may present with varied presentations post-NAT, a healthy suspicion is required for effective diagnosis. Infants with NAT and, rarely, accidental subdural hemorrhage may exhibit a clinicoradiologically dissociative presentation, with their behavior appearing to reflect better function than what becomes apparent with maturation. Injury to the developing brain can result in extensive damage consistent with the “big black brain” phenomenon, which predicts poor prognosis. Sequential magnetic resonance imaging (MRI) is important to understand insults to the developing brain for follow-up and prognostication. Pediatric traumatic brain injury (TBI) is a major cause of concern worldwide. NAT brain injury is common in infants, who may present with varied presentations post-NAT, hence, a healthy suspicion is required for effective diagnosis. Infants with NAT and, rarely, an accidental subdural hemorrhage may exhibit a clinicoradiologically dissociative presentation with their behavior appearing to reflect better function than what becomes apparent with maturation. Injury to the developing brain can result in extensive damage consistent with the “big black brain” phenomenon, which predicts poor prognosis. Sequential MRI is important to understand insults to the developing brain for follow-up and prognostication.